REQUEST TO ADD LICENSED CLINICIAN

REQUEST TO ADD LICENSED CLINICIAN Name License or Certification DOB mm / dd / NPI # yyyy What NPI# will be used for billing? Individual NPI Hire Date Agency/Group NPI only (credentialing required) Both (credentialing required) (credentialing not required) Agency/Practice Name CAQH # (if known) Taxonomy # Currently Credentialed with Trillium YES NO (If NO, Credentialing Specialist will follow-up with request for additional information) Business Contact Person E-Mail Address CURRENTLY WORKING WITH Agency/Practice Name Address City State Zip+4 City State Zip+4 Physical Address City State Zip+4 Office Phone Office Fax State Zip+4 PREVIOUSLY WORKED WITH Agency/Practice Name Address End Date mm / dd / yyyy PRIMARY OFFICE ADDRESS SECONDARY OFFICE ADDRESS (if applicable) Physical Address City Office Phone Office Fax EMPLOYER FEDERAL TAX I.D. NUMBER Copy of Agency Certificate of Insurance (with name of LIP, dates of coverage, and coverage amount) - attached Copy of all Licenses/Certifications-attached SUBMITTED BY: Signature Date PLEASE E-MAIL THE COMPLETED FORM with Attachments TO Credentialing@TrilliumNC.org INCOMPLETE FORMS WILL NOT BE ACCEPTED FOR OFFICE USE ONLY Date Initial Request Received: Date Added to MCO Roster: Revised 4.2016 24-Hour Crisis Care & Service Enrollment - 877.685.2415 Business & Administrative Matters - 866.998.2597 TrilliumHealthResources.org

Dear Provider/Practitioner: Thank you for your interest in enrolling in the Trillium Health Resources Provider Network. In this packet you will find all of the information and documents necessary to complete the Trillium Health Resources application packet for credentialing. Included in this packet are the following items: Two (2) Trillium Health Resources Provider Evaluation Forms to be returned directly to Trillium Health Resources Trillium Health Resources Attestation Statement Trillium Health Resources LIP Cultural, Racial, Ethnic, Gender and Linguistic Data Form Verification Form to Conduct Background Checks (Background Authorization Form) In order for an application to be complete, a prospective Licensed Practitioner (or Associate Practitioner) will need to submit the following information in the order listed below and it must be complete: 1. Complete Application via CAQH Proview- http://www.caqh.org/overview.php check inbox and spam folders for information from CAQH regarding application process. ALL FIELDS ON THE CAQH APPLICATION MUST BE COMPLETE (TO INCLUDE COVERING COLLEGUES ). Once your completed application has been submitted, we will include you on our roster at which time you will be able to upload the CAQH attestation. 2. Copy of the Provider s original state(s) clinical license and current registration. If provisionally licensed, submit a current copy of your supervision contract from the appropriate licensure board. Include an attestation from the clinical supervisor stating that the provisionally licensed provider is receiving supervision and that the supervisor approves the supervision contract. 3. Copy of DEA certificate for MDs, Physician Assistants and Nurse Practitioners (Must have a valid date and refer to current address) 4. Copy of the face sheet of current professional liability insurance policy, indicating by name, provider(s) covered, coverage amounts, effective date, expiration date, 24-Hour Crisis Care & Service Enrollment - 877.685.2415 TrilliumHealthResources.org 112 Health Drive, Greenville, NC 27834-7704 866.998.2597 Fax: 252.215.6883

Page 2 of 3 and policy number (unless already submitted with the Request to Add form) or a copy of the certificate of insurance (declaration page). 5. Copy of certificate from any specialty board, if applicable. All MDs, PAs, and Nurse Practitioners who are Board Certified must submit a copy of their Board certificate(s). 6. Copy of Educational Commission for Foreign Medical Graduate Certificate ECFMG, if Applicable. 7. Two (2) Trillium Health Resources Provider Evaluation Forms or two Letters of Professional Reference dated within the last six (6) months. At least one of the references must be from a like-licensed practitioner. Trillium Health Resources reserves the right to call at least one (1) reference. 8. Copy of Curriculum Vitae or work history after graduation from Medical, Dental, or other professional school. The CV must account for any gaps of one hundred eighty (180) days or more. 9. Copy of W-9 Form (for Independent Practitioner seeking a network contract only) 10. Copy of original transcripts from the college/university for the highest degree obtained. All MDs and PAs must submit a copy of their transcript if they are not Board certified. Please submit completed applications to the following email address no more than 60 days prior to the practitioners projected start date Credentialing@TrilliumNC.org Trillium Health Resources shall review your credentials at the first Credentialing Committee meeting after the application packet is deemed complete. PLEASE NOTE INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED. INCOMPLETE APPLICATIONS WILL BE DENIED AND RETURNED TO THE PROVIDER. NO EXCEPTIONS. As part of the Credentialing Program, each practitioner has the following rights: 1. To review information collected during the credentialing process except references and NPDB, upon request 2. To be informed of the status of their credentialing application, upon request 3. To be notified of information that is significantly different than reported by you and to have the opportunity to correct erroneous information in writing 4. To be notified about the Credentialing Committee's decision within ten (10) business days of the committee s decision or Medical Director s approval Once your Application Packet has been reviewed and your Credentialing has been approved, a contract will be executed if applicable. At which time you will be assigned a Network Coordinator to serve as your Network point of contact going forward. Trillium Health Resources Businessn& Administrative Matters: 866.998.2597

Page 3 of 3 IMPORTANT: Licensed practitioners must be fully credentialed before providing services for any Trillium Health Resources enrollees. Thank you for your interest in Trillium Health Resources. For inquiries regarding the application process or status, please contact our Credentialing Unit at Credentialing@TrilliumNC.org Trillium Health Resources Businessn& Administrative Matters: 866.998.2597

Trillium Health Resources Provider Evaluation Form Peer (Licensed Practitioner, not partner) Referring Physician or Practitioner Chief of Department/Staff where practitioner has admitting privileges (t partner) Name of the Applicant: Supervisor Group Name: The above provider is an Trillium Health Resources network applicant. Please provide us with information concerning his/her professional qualifications. All information submitted will be held in strict confidence. 1. What is your specialty/credential(s)? 2. What is your relationship to the applicant? 3. How long have you known the applicant? 4. How would you rate the applicant s professional abilities? Excellent Very Good Good Fair Poor 5. How would you rate the applicant s ability to work and communicate with physician and non-physician staff? Excellent Very Good Good Fair Poor 6. How would you rate the applicant s rapport with consumers/clients? Excellent Very Good Good Poor Fair 7. What do you believe to be the applicant s strengths and weaknesses (if any)? a) Strengths: b) Weaknesses: 8. To your knowledge, has the applicant had any of the following: Malpractice claim(s)? Problems with medical licensure, certification, or licensing boards? Revocation, denial, or change in hospital privileges? History of/or current impairment due to drugs and/or alcohol? If your answer is yes to any of the above questions, please provide details. 9. Would you recommend this person as a provider for the Trillium network? Without reservation With reservation Would not recommend 10. Please provide any other information that would be helpful to us in evaluating this applicant. Evaluator s Signature: Printed Name: Address: Group Name Date: Telephone: Street City State Zip Revised 4/2016 24-Hour Crisis Care & Service Enrollment - 877.685.2415 Business & Administrative Matters- 866.998.2597 TrilliumHealthResources.org

Trillium Health Resources Provider Evaluation Form Peer (Licensed Practitioner, not partner) Referring Physician or Practitioner Chief of Department/Staff where practitioner has admitting privileges (t partner) Name of the Applicant: Supervisor Group Name: The above provider is an Trillium Health Resources network applicant. Please provide us with information concerning his/her professional qualifications. All information submitted will be held in strict confidence. 1. What is your specialty/credential(s)? 2. What is your relationship to the applicant? 3. How long have you known the applicant? 4. How would you rate the applicant s professional abilities? Excellent Very Good Good Fair Poor 5. How would you rate the applicant s ability to work and communicate with physician and non-physician staff? Excellent Very Good Good Fair Poor 6. How would you rate the applicant s rapport with consumers/clients? Excellent Very Good Good Fair Poor 7. What do you believe to be the applicant s strengths and weaknesses (if any)? a) Strengths: b) Weaknesses: 8. To your knowledge, has the applicant had any of the following: Malpractice claim(s)? Problems with medical licensure, certification, or licensing boards? Revocation, denial, or change in hospital privileges? History of/or current impairment due to drugs and/or alcohol? If your answer is yes to any of the above questions, please provide details. 9. Would you recommend this person as a provider for the Trillium network? Without reservation With reservation Would not recommend 10. Please provide any other information that would be helpful to us in evaluating this applicant. Evaluator s Signature: Printed Name: Address: Group Name Date: Telephone: Street 24-Hour Crisis Care & Service Enrollment - 877.685.2415 Business & Administrative Matters - 866.998.2597 City State Zip Revised 4/2016 TrilliumHealthResources.org

Licensed Independent Practitioners Cultural, Racial, Ethnic, Gender, and Linguistic Data Form (This information will reside within Trillium Health Resources Provider Directory and the online Provider Search) This form is not part of the Trillium Health Resources Credentialing Process. By providing the information below, you will be assisting Trillium Health Resources with consumer/provider matching as well as providing information necessary for analyzing our Network and its ability to meet our Consumers cultural, racial, ethnic and linguistic needs. Name of Practitioner: Name of Practice: E-mail Address: (This section is self-reported information and requires no backup documentation) Counties Served: Beaufort Chowan Hertford rthampton Perquimans Bertie Craven Hyde Onslow Pitt Brunswick Currituck Jones Pamlico Tyrrell Camden Dare Martin Pasquotank Washington Carteret Gates New Hanover Pender OTHER: Provider Type:APPCNS (Advanced Practice Psychiatric Clinical Nurse Specialist) LCSW LCAS NP-Psychiatric LMFT LPA PA Priority Populations: MH Adult MH Child Your Gender: Female PhD SA Adult SA Child LPC MD PsyD Other DO DD - Adult DD Child Male Your Race and/or Ethnicity: (Please check [ ] all appropriate categories) White Black or African American American Indian and Alaska Native Asian, Pacific Islander Hispanic or Latino Other 24-Hour Crisis Care & Service Enrollment - 877.685.2415 Business & Administrative Matters - 866.998.2597 TrilliumHealthResources.org

Trillium - Licensed Independent Practitioners Cultural, Racial, Ethnic, Gender, and Linguistic Data Form Page 2 of 4 Population(s) You Serve: (Please check [ ] all that apply) Early Childhood (0-4) Child & Adolescent (5-21) Adult (22+) Geriatrics (55+) Women Gay & Lesbian HIV/Aids Hearing Impaired Men Gender Identity Issues Sexually Reactive/Aggressive Youth Visually Impaired Licensed Independent Practitioners Practice Preference Data Culturally Diverse Populations You Feel Competent to Treat: (Please check [ ] all that apply) White Black or African American Asian, Pacific Islander American Indian and Alaska Native Hispanic or Latino Other Language(s) You Are Able to Communicate in Fluently: (Please check [ ] all that apply) American Sign Language English French German Portuguese Spanish Telugu Other Russian Hmong (The sections below must have backup documentation to be listed with Trillium Health Resources) Focus of Treatments You Provide: (Please check [ ] all that apply) Amnestic Disorder Anxiety/Phobias Attention Deficit Hyperactivity Disorder Autism - Asperger s Bipolar Disorder (manic-depressive illness) Chemical Dependency/Substance Abuse Conduct Disorders Co-Occurring/Dual DX Mental Retardation/Mental Illness, Mental Health/Substance Abuse Dementia Disorder Depression Eating Disorders Factitious Disorders Impulse Control Mentally Retarded/Developmentally Disabled Obsessive-Compulsive Disorder Personality Disorders Post Traumatic Stress Disorder Schizophrenia and other Psychotic Disorders Sexual & Gender Identity Disorders Sleep Disorders Somatoform Disorders Traumatic Brain Injury

Trillium - Licensed Independent Practitioners Cultural, Racial, Ethnic, Gender, and Linguistic Data Form Page 3 of 4 Clinician Expertise/Certified Specialties: (Please check [ ] all that apply) Psychological Testing Therapy/Service Type Trauma Focused Cognitive/IQ Anger Management Abuse- Physical, Sexual, and/or Emotional Developmental limited/extended Assessment Evaluation Forensic Screening/Evaluation Career/Vocational Counseling Maltreatment Neuro Psych Cognitive Behavioral Therapy Neglect Personality Crisis/Solution-Focused Brief Therapy Rape Dialectical Behavior Therapy Faith Based Counseling General Psychiatry General Psychology Gero Psychiatry Grief and Loss Therapy Health Psychology Chronic Medical conditions Marriage and Family Counseling Play Therapy, Filial Relaxation/Meditation-Hypnotherapy Self-Direction

Trillium - Licensed Independent Practitioners Cultural, Racial, Ethnic, Gender, and Linguistic Data Form Page 4 of 4 Clinician Expertise/Certified Specialties that Require Verification: (Please check [ ] all that apply) Verification of specific expertise(s) and/or training(s) selected below must accompany this form for Trillium Health Resources recognition, i.e. training certificates, certification, supervisor letters verifying training, or proof of experience. If standard training for clinician s licensure does not include area of identified expertise, additional documentation to support expertise will be required, e.g. a Psychiatrist who does psychological testing. Addiction Psychiatry Eye Movement Desensitization and Reprocessing Therapy (Fellowship in addiction psychiatry/board Certification/ ASAM Certification/Experience) (Training Certificate/experience) Addiction Treatment Forensic Psychology/Psychiatry (LCAS/CAS/CCS/ Experience) (Fellowship in Forensic Psychiatry/Board Certification/Training/Experience) Child Psychiatry Trauma Focused Cognitive Behavioral (Fellowship in Child Psychiatry/Board Certification Experience) (Course Completion at MUSC, Duke or NCTSN) Dialectical Behavior Therapy (Certification, Supervision, and Experience) Neuro Psych Assessment (Training, Supervision, and Experience) Services Provided in Office: Services Provided in the Community: Signature Date: Thank you for taking the time to submit this form. If this form is not completed and returned, your provider information will not appear within the Trillium Health Resources online Provider Search or Provider Handbook. Revised: 04.2016

Attestation Statement - LIP (IMPORTANT: Submit Original Only) This Application is to be signed by each individual provider submitting an application. Stamps or Copies Please All information submitted by me in this application, as well as any attachments or supplemental information, is true, current, and complete to my best knowledge and belief as of the date of signature below. I fully understand that any significant misstatement in this application may constitute cause for denial of my application or termination of a resulting participation agreement. By application for membership in Trillium Health Resources, I signify my willingness to appear for interview in regard to my application. I authorize Trillium Health Resources to consult with administrators and members of the medical staffs of hospitals or institutions with which I have been associated and with others, including past and present malpractice carriers, who may have information bearing on the questions in this application. Upon request, I will obtain and provide to Trillium Health Resources materials pertaining to my qualifications and competence, including, materials relating to complaints filed, any disciplinary action, suspension, or action to curtail my medical- surgical privileges. I further consent to the inspection by representatives of Trillium Health Resources of all documents that may be material to an evaluation of my professional qualifications and competence. I understand and agree that I, as an applicant, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications and for resolving any doubt about such qualifications. I release from liability all representatives of Trillium Health Resources for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and I release from any liability, all individuals and organizations that provide information to Trillium Health Resources in good faith and without malice concerning this application and I hereby consent to the release and verification of information relating to any disciplinary action, suspension, or curtailment of medicalsurgical privileges to Trillium Health Resources. I understand that if my application is rejected for reasons relating to my professional conduct or competence, Trillium Health Resources may report the rejection to the appropriate state licensing board and/or National Practitioner Data Bank. In the event I am accepted for participation in Trillium Health Resources Network, I hereby consent to Trillium Health Resources for inspection of my patient records relating to Trillium Health Resources enrollees as necessary for its peer and utilization review purposes as permitted by state or federal law and regulation. I further agree to notify Trillium Health Resources in a timely manner (not to exceed 30 days) of any changes to the information requested on the initial application. PRINT NAME OF PROVIDER SIGNATURE OF PROVIDER DATE Please Sign and Date This Attestation Statement Revised 04.2016 Uniform Application to Participate as a Health Care Practitioner 24-Hour Crisis Care & Service Enrollment - 877.685.2415 TrilliumHealthResources.org 112 Health Drive, Greenville, NC 27834-7704 866.998.2597 Fax: 252.215.6883

Authorization form for verification checks NAME MAIDEN NAME (First, Middle, Last) (If applicable) CURRENT ADDRESS: CITY, STATE, ZIP HOW LONG? 1ST PREVIOUS ADDRESS CITY, STATE, ZIP HOW LONG? 2ND PREVIOUS ADDRESS CITY, STATE, ZIP: HOW LONG? APPLICANT SOCIAL SECURITY NUMBER: DATE OF BIRTH DRIVER S LICENSE # AND STATE ISSUED: EMAIL ADDRESS (may be used for official correspondence): CONSUMER DISCLOSURE I understand that Trillium Health Resources may rely on one or more consumer reporting agencies such as IntelliCorp, Inc. to obtain a consumer report(s) or investigative consumer report(s) (criminal background check, Databank, etc.) for credentialing purposes and I attest that all personal data provided is true, accurate, and complete. APPLICANT AUTHORIZATION I hereby authorize Trillium Health Resources to obtain and rely upon consumer reports or investigative consumer reports for the purpose of credentialing. Applicant s Signature Date For office use only Reports Obtained: Date Verification Criminal Record Obtain: NPDB Verified By: Revised 4.2016 24-Hour Crisis Care & Enrollment Service - 877.685.2415 Business & Administrative Matters- 866.998.2597 TrilliumHealthResources.org